336 (336)    MH REPORT (601.93)

|
|   DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|   Gender: <.Patient_Gender.>
|  
|<*Answer_7771*>
|  
|  
|Questions and Answers:
|  
|   1.  This questionnaire asks about experiences you may have had after a
|very stressful experience.  Please indicate whether you had at least one 
|Moral Injury Outcome Scale and Brief Inventory of Psychological Functioning (MIOS+B-IPF_V2)
|experience as described below that is currently distressing 
|(select all that apply).
|
|<*Answer_7772*>
|
| MIOS
|   2.  I blame myself.
|       <*Answer_9284*>
|   3.  I have lost faith in humanity.
|       <*Answer_9285*>
|
|   4.  People would hate me if they really knew me.
|       <*Answer_9286*>
|   5.  I have trouble seeing goodness in others.
|       <*Answer_9287*>
|   6.  People don't deserve second chances.
|       <*Answer_9288*>
|   7.  I am disgusted by what happened.
|       <*Answer_9289*>
|   8.  I feel like I don't deserve a good life.
|       <*Answer_9290*>
|   Date Given: <.Date_Given.>
|   9.  I keep myself from having success.
|       <*Answer_9291*>
|  10.  I no longer believe there is a higher power.
|       <*Answer_9292*>
|  11.  I lost trust in others.
|       <*Answer_9293*>
|  12.  I am angry all the time.
|       <*Answer_9294*>
|  13.  I am not the good person I thought I was.
|       <*Answer_9295*>
|   Clinician: <.Staff_Ordered_By.>
|  14.  I have lost pride in myself.
|       <*Answer_9296*>
|  15.  I cannot be honest with other people.
|       <*Answer_9297*>
| B-IPF
|  16.  For the following questions of the B-IPF assessment, reflect on
|       how much this experience made it hard for you to function 
|       in each of the areas listed.
|       <*Answer_9298*>
|  17.  I had trouble in my romantic relationship with my spouse or
|   Location:  <.Location.>
|       partner.
|       <*Answer_9299*>
|  18.  I had trouble in my relationship with my children.
|       <*Answer_9300*>
|  19.  I had trouble with my family relationships.
|       <*Answer_9301*>
|  20.  I had trouble with my friendships and socializing.
|       <*Answer_9302*>
|  21.  I had trouble at work.
|       <*Answer_9303*>
|  
|  22.  I had trouble with my training and education.
|       <*Answer_9304*>
|  23.  I had trouble with day to day activities, such as doing household
|       chores, running errands and managing my medical care.
|       <*Answer_9305*>
|  
|Information contained in this note is based on a self-report assessment 
|and is not sufficient to use alone for diagnostic purposes. Assessment 
|results should be verified for accuracy and used in conjunction with 
|other diagnostic activities.
|   Veteran:  <.Patient_Name_Last_First.>
|   SSN: <.Patient_SSN.>